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What explains surge in coronavirus numbers in India? |NationalTribune.com

New Delhi, India – India has added another 300,000 coronavirus infections to its caseload in the past four days, an infection rate which could see it overtake the United States to become the world’s worst-affected country within weeks. The country registered 96,551 new cases – a fresh global record – on Friday. On Monday, India…

What explains surge in coronavirus numbers in India? |NationalTribune.com

New Delhi, India – India has added another 300,000 coronavirus infections to its caseload in the past four days, an infection rate which could see it overtake the United States to become the world’s worst-affected country within weeks.
The country registered 96,551 new cases – a fresh global record – on Friday.
On Monday, India had surpassed Brazil as the country with the second-highest number of coronavirus cases in the world, with 4.2 million cases. The US has a caseload of 6.4 million infections.
More than 76,000 people in India have died due to the coronavirus, which has killed more than 909,000 people worldwide. 
India’s health ministry says the surge in cases is due to an increase in daily testing that has now exceeded one million.
Despite the steep surge in new cases and deaths, India continues to ease restrictions and open up its economy to make up for losses incurred during its long and punishing lockdown period, which experts believe was rushed through and “illogical”.
The lockdown was wrong, it just destroyed our economy.
Dr Jayaprakash Muliyil, epidemiologist

The March lockdown forced hundreds of thousands of workers to flee cities for their homes, and experts say it probably contributed to the spread of the virus in rural areas.
Moreover, they say that the government has not successfully communicated an effective and uniform message on masking, social distancing and congregation – measures that could have helped contain the spread of the outbreak.
As the infections spike in rural areas, health experts say the country’s crumbling rural health sector is not equipped to deal with the surge in cases in the world’s second-most populous nation.
The only silver lining for the government is the high recovery rate (77 percent) and the low mortality rate (1.6 percent) – points the government continues to emphasise.
Poor health infrastructure
Even in cities, patients have had to suffer due to poor hospital facilities and protocols. Mohinder Kaur, who was admitted to a government-run Guru Teg Bahadur Hospital in the capital, New Delhi, after testing COVID-19 positive, told Al Jazeera of her ordeal.
“No one would come near us or even help us. If anyone would accidentally touch us, the staff would shout at them for ruining a PPE (personal protective equipment) kit, the 75-year-old retired school teacher told Al Jazeera.
If lockdown was not enforced earlier, we would have been in an even worse position.
Bizay Sonkar Shastri, BJP’s national spokesperson

“In this heat, the fans were not working and the staff would not get them fixed despite several complaints. The toilets were filthy and sometimes had no water. The ward had rats, lizards, cats and even dogs roaming around. It was a living hell and we are fortunate to have survived this,” she said.
India’s capital still has better health facilities in comparison to rural areas where only 20 percent of India’s doctors and 40 percent of hospitals are located. Health experts feel that this could put millions of people at risk.

People stand in a queue as they wait for their turn to collect test reports for the COVID-19  at a hospital in the northern Indian city of Amritsar [File: Narinder Nanu/AFP]

“India’s epidemic is two-part, urban followed by rural, each consisting of innumerable outbreaks – each district or city/large town with its own outbreak, the sum total is what is seen in numbers,” said Dr T Jacob John, epidemiologist and former professor at Christian Medical College, Vellore.
“In the last week of August, the epidemic reached all nooks and corners – evidenced by infection among tribal communities. That means, spatially the epidemic has peaked,” he said.
Stage four of the pandemic
John says India has entered stage four of the pandemic, which means the country is seeing widespread transmission, and that is reflected in the record number of daily infections in the past several weeks.
But the government has so far steadfastly denied community transmission, during which the source of contagion is not known. John says India witnessed community transmission (stage three) between March and July.
Mask-wearing and avoiding crowding, school closure etc has definitely flattened the curve a little bit, not as much as we could have achieved had we done lockdowns in a planned manner.
Dr T Jacob John, epidemiologist and former professor at Christian Medical College, Vellore

The epidemiologist said authorities must move from the idea of “control” to “mitigation”.
Preeti Kumar, vice president, public health system support at the Public Health Foundation of India (PHFI), a public-private non-profit, pointed out that India is a federal state and health is largely a state subject.
“Each state has implemented the response based on the strength of its health system and available resources,” Kumar told Al Jazeera.
“Kerala and Punjab states introduced lockdowns even before the rest of the country did. Four southern states (with stronger health systems) have also tested more and reported better.
“In contrast, the poorer northern states with weaker health systems, are only now beginning to feel the impact and are struggling with testing, tracing, treating and reporting,” she said.
According to Kumar, the Indian government provided much of the leadership in the early stage of the pandemic, and continues to support through strategic guidelines, expertise and some level of funding.
Ineffective lockdown
Prime Minister Narendra Modi’s Bharatiya Janata Party (BJP) government had introduced one of the world’s strictest lockdowns, triggering a working-class exodus from cities to rural areas and smaller towns.
The two-month lockdown led to the shuttering of factories and loss of millions of jobs, and experts say the decision, taken at four hours’ notice, was “ineffective and unscientific”.

Security guards frisk commuters at a metro train station New Delhi [File: Adnan Abidi/Reuters]

“The lockdown was wrong, it just destroyed our economy,” said Dr Jayaprakash Muliyil, epidemiologist and chairperson of the Scientific Advisory Committee of the National Institute of Epidemiology.
Calling it a rushed move, Christian Medical College’s John said India’s lockdown had no scientific support. “National lockdown was illogical. It was necessary in different states at different times as they reached phase three,” he said.
Meanwhile, Kumar of PHFI believes that other countries like South Korea, Japan, Thailand and Taiwan did not see the rise in cases the way India has seen post-lockdown because they had invested heavily in testing, contact-tracing and quarantine.
“Lockdown was declared to help buy time to prepare the system to cope – prepare facilities, equipment, consumables, testing labs, surveillance systems and health workforce,” Kumar said.
“These countries also had widespread use of masks, distancing, etc. These interventions together helped flatten the curve. Our scale-up in testing has taken more time, starting from a very low base. Lastly, our public measures and awareness on masking, hygiene and distancing are very low.”
In India, especially in rural areas and even semi-urban areas, poor hygiene standards and lack of social distancing measures further contributed to the spread of the virus, experts say.
“Poor sanitation is the government’s failure,” said John.
Beyond the big metros, there is little information on wearing masks. I think the communication has not been sufficiently effective and sustained to spread awareness about it.
Preeti Kumar, vice president, the Public Health Foundation of India

Kumar from PHFI blamed the government for not successfully communicating an effective, uniform message on masking, distancing and congregating.
“Beyond the big metros, there is little information on wearing masks. I think the communication has not been sufficiently effective and sustained to spread awareness about it. Opening up is being perceived by people as if the epidemic is no more a threat. This incorrect perception needs to be addressed,” she added.
According to her, countries which have managed to flatten the curve have relied on the government to scale up testing, contact tracing and treatment. “Alongside, they have effective policies on active public engagement on masking and distancing,” she told Al Jazeera.
India has conducted 54 million tests so far, compared with the US which has conducted more than 90 million tests. The US population is a quarter of India’s 1.4 billion people.
Governing party spokesman defends gov’t
On flattening the curve, John said, “Mask-wearing and avoiding crowding, school closure etc has definitely flattened the curve a little bit, not as much as we could have achieved had we done lockdowns in a planned manner.”
The only silver lining for India in its fight against the pandemic is its low mortality rate. Experts say the mortality rate is also low in neighbouring countries.
“Fortunately, COVID-19 mortality is quite low in India, Pakistan, Bangladesh and Sri Lanka. Median age in these countries is below 30 and that is one reason for the low mortality. Mortality is also declining globally – my hypothesis is that the virus is becoming less virulent, a natural phenomenon in new hosts and multiple generations of virus growth,” said John.
A spokesman from the BJP defended the Modi government’s management of the pandemic.
“Those who are saying that lockdown was unscientific have wrong intentions,” Bizay Sonkar Shastri, BJP’s national spokesperson, told Al Jazeera.
“It is because of lockdown that our daily numbers are at around 90,000, otherwise they would been in lakhs [hundred of thousands]. If lockdown was not enforced earlier, we would have been in an even worse position.
“Those who are raising questions about the lockdown are anti-Modi and anti-BJP,” he said.

India’s health ministry says the surge in cases is due to an increase in daily testing that has now exceeded one million [File: Diptendu Dutta/AFP]

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‘No miracle’: What explains Bali’s low coronavirus cases?

Denpasar, Indonesia – The Indonesian resort island of Bali, which received half a million international tourists a month until visas on arrival were halted on March 20, is now the site of a medical mystery that has beguiled many: There are no visible signs of a widespread coronavirus pandemic here. Days after new tourists were banned and…

‘No miracle’: What explains Bali’s low coronavirus cases?

Denpasar, Indonesia – The Indonesian resort island of Bali, which received half a million international tourists a month until visas on arrival were halted on March 20, is now the site of a medical mystery that has beguiled many: There are no visible signs of a widespread coronavirus pandemic here.
Days after new tourists were banned and when much of the world was locking down, tens of thousands of Balinese attended Hindu ceremonies marking the New Year.
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Life in the Balinese capital, Denpasar, continues as normal as Al Jazeera witnessed last weekend in the city’s bustling wet markets.
As of Saturday, there were only 235 confirmed COVID-19 cases on the island, including 121 recoveries and four deaths – figures that fly in the face of predictions by contagious disease experts cited in reports by Al Jazeera and other news sources, which warned Bali could emerge as a coronavirus hotspot in Indonesia.

Looking for answers
Bali’s apparent immunity to COVID-19 has generated much discussion on social media, representing a wide gamut of opinion that also reflects the island’s spirituality and mysticism.
Others cite conspiracy theories that claim the pandemic is a hoax invented by overzealous governments and vaccination figureheads like Bill Gates.
Gede Wanasari, head priest of the Indonesia Hinduism Society, told Al Jazeera Bali was spared because of the good karma and prayers of the Balinese people.
He also points to Balinese cuisine, saying it “contains a lot of herbs to increase human immunity” – a theory supported by some studies and nutrition experts on the island.

Tourism in Bali has ground to a halt, but life in the capital Denpasar continues as normal including at the bustling markets [Ian Neubauer/Al Jazeera]

From a medical perspective, Dr Panji Hadisoemarto, an epidemiologist at Padjadjaran University in Java, has also been pondering Bali’s apparent immunity to COVID-19.
“When COVID-19 was first identified in Wuhan, I thought Bali would be one of the first places to be hit hard because of all the Chinese tourists,” he said.
“I was wrong, and I’m starting to question the assumptions behind these models because the rate of transmission is a lot lower than expected. But the real question is – is this real or just an artefact of under-reporting?”
Indonesia has one of the worst COVID-19 testing rates in the world – only 374 for every million compared with 20,241 for every million in the United States and 24,600 in Singapore, according to coronavirus tallying site Worldometer. In Bali, an island of about four million people, only about 1,300 tests have been conducted so far.
No signs of health emergency
Indonesian President Joko Widodo previously admitted to holding back some information on COVID-19 to prevent the public from panicking, while Al Jazeera heard allegations from two independent sources that some health officials in Bali have botched the handling of test results.
And while data can be suppressed, large numbers of people becoming ill or dying on an island the size of Bali cannot.

A Balinese family enjoys a picnic in front of a temple in Batu Bolong Beach in Canggu before the coronavirus pandemic [Ian Neubauer/Al Jazeera]

When Al Jazeera visited Udayana University Hospital in Bali last weekend, there was no one outside the emergency ward.
At Sanglah Hospital, the largest on the island, nine people were waiting for attention – none of whom displayed outward symptoms (such as a dry cough) of COVID-19.
Meanwhile, gravediggers at the largest burial grounds on the island – Kampung Jawa Muslim Cemetery and Taman Mumbul Crematorium – said they had not been busier than usual since the pandemic began.
Misdiagnosis
Dr Hadisoemarto said there are two possible answers to the mystery.
“Either there is no transmission in Bali, or the transmission is silent because people are getting infected but most of them are asymptomatic,” he said, adding that either answer leads to more questions.
“Does it have anything to do with genetics, the lifestyle in Bali or how the virus behaves in the tropics?”

Dr Dicky Budiman, an epidemiologist who has helped formulate Indonesia’s Ministry of Health pandemic management strategy for 20 years, also believes the real number of COVID-19 in Bali is much higher than the official tally.
He said the spread is going undetected because of a lack of testing and underreporting caused by cultural norms that encourage traditional healing at home.
He also theorised that many COVID-19 infections in Bali are being misdiagnosed as dengue fever – a disease spread by mosquitoes.
“There is an extraordinarily high number of dengue cases in Bali right now – more than 2,100 cases – and I believe that is because testing for dengue is easier, cheaper and faster than testing for COVID-19.”
Asymptomatic outbreak?
The theory is corroborated by a recent study in the peer-reviewed medical journal, The Lancet, which describes two patients in Singapore who received false-positive results for dengue and were later confirmed to have COVID-19.
Budiman said the unusually low COVID-19 mortality rate in Bali could be attributed to an asymptomatic outbreak.

A couple wash their hands at one of thousands of free hand-washing stations set up across Bali under a sign that says masks are compulsory at the wet market in the capital Denpasar [Ian Neubauer/Al Jazeera]

“We know 80 percent of all cases around the world are asymptomatic because they are related to young adults. I believe that’s taking place in Bali – most cases are asymptomatic because of the young demographic,” he said.
Udayana University Professor Gusti Ngurah Mahardika, Bali’s most senior virologist, also believes the island’s demographics are playing a factor.
“If you look at the age structure in Bali, the median age is only 30. But if you compare it to America where 16 percent of the population is more than 70 years old and in Italy where it’s 20 percent, it provides a reasonable explanation as to the low number of reported cases and the low mortality rate in Bali.”
The heat theory
Mahardika pointed out that the virus does not transmit as effectively in tropical climates like Bali’s.
“I have published a paper that argues COVID-19 might be sensitive to heat and humidity as has been reported with MERS and SARS,” he says.
Last week, President Jokowi shared the so-called “heat theory” with reporters.

All the beach areas in Bali have been closed to tourism to help contain the spread of the coronavirus [Ian Neubauer/Al Jazeera]

“The higher the temperature, the higher the humidity and direct exposure to sunlight will further shorten the life span of the COVID-19 in the air and on non-porous surfaces. This is good news for Indonesia,” the president said, basing his statement on “emerging findings” released by the US Department of Homeland Security.
But the heat theory fails to account for infection rates in Singapore, which has very similar meteorological conditions to Bali, but experienced a daily jump of more than 1,400 confirmed COVID-19 cases on April 20 – despite having one of the world’s strictest lockdowns.
In the Brazilian city of Manaus, where meteorological and demographical conditions are also almost identical to those in Bali, Mayor Virgilio Neto described the situation as a “horror movie”, with bodies piling up in refrigerated trucks, mass graves being dug outside cemeteries and a healthcare system that has collapsed.

Mahardika, Bali’s foremost virologist, who was initially puzzled by events in Manaus, later commented the only variable left to consider are some Brazilian cultural norms and lifestyle involving closer physical contact among its people compared with the Balinese.
Mahardika qualifies his responses by saying it is all guesswork because of the limited testing.
“There is no transparency of data in Indonesia, so all we can do is speculate. But one thing’s for sure: There’s no miracle in Bali.”
Dr Hadisoemarto concurs: “The truth is no one can explain what is happening in Bali. It’s very interesting, and someone needs to go there and do the research because it could help us come up with an answer to stop COVID-19 in its tracks.”
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